1981 – a watershed moment for reconstructive surgery in the limb – saw Gavril Ilizarov bring to an audience in Bellagio, Italy, multiple astounding examples of reconstructive procedures hitherto never seen in the West. Since then, his principles, techniques, and his original device (still used together with other iterations based on the original) have led to countless limbs successfully saved through the regenerative capacities of his technique of distraction histogenesis.

With over 30 years' experience of this method in the West, surgeons have been able to offer limb salvage when limb loss would have been the norm. Some even argue that – contentiously – limb amputation is unnecessary for all congenital limb deficiencies. Added to this is the continual introduction of newer technologies which make the process of distraction histogenesis more patient friendly (e.g., through implantable devices). Has Ilizarov's method become that which lays amputation as a procedure to the rest?

Now – the 21st century – is when a moment's pause is called for. Are we really doing our best for patients if we were to pursue salvage above all else? Is amputation such a dreaded outcome? Can the outcome from reconstructive surgery be worse?

A limb amputation is a lifesaving procedure that should be undertaken with confidence when trauma produces catastrophic uncontrolled hemorrhage, when the warm ischemia time of the limb exceeds 6 h, where there is extensive crush especially of the foot, and where the injury itself is a near-complete amputation.[1] These scenarios simply tell of a dead limb-in-waiting or, worse still, a dead patient if the procedure is not carried out expeditiously.

However, many clinical scenarios are more complex and pose conflicting indications: what if there is extensive muscle loss from two out of the three compartments of the leg; what if the bone loss exceeds 1/3rd or 1/2nd the length of the tibia; and what if the warm ischemia time is just <6 h? The decision to save or sacrifice the limb will depend on multiple factors, many of which are not just patient related. In each case, the patient's physiological, psychological, social, and economic reserves to absorb limb loss or that of protracted multiple surgeries for limb salvage need to be weighed. And, there the matter does not end – are the team and hospital the right ones to be offering reconstructive options?

A conflict of interest presents itself to surgeons who reflect on this conundrum; if salvage of the limb through reconstruction is offered and successful, the surgeon is hailed the hero, whereas if amputation is done even though the more appropriate option, there is a risk the surgeon's reputation is sullied through a perceived inability for complex problems.

The published evidence on the outcomes of limb salvage through reconstruction and that of amputation is there: amputees can function as well as those with successfully reconstructed limbs, especially if the level of amputation preserves the knee joint.[2],[3],[4],[5],[6] The recovery is quicker and short and medium-term costs are less than that for reconstruction, but this balance reverses in the long term when costs of supplying prostheses throughout the lifetime of the patient strips this difference altogether.[7] Clearly, both limb reconstruction and limb amputation (especially that below the knee) are viable options for treatment in the 21st century.

With the advances made in both devices and implants for limb reconstruction and that too in the world of limb prosthetics, we need to – as surgeons who offer both – ask the fundamental question behind these problems: what are we trying to achieve? Are we trying to save the limb at all costs now that we have the ability? Are we going to suggest a trial of treatment by reconstruction and then amputate if we fail? While these questions may seem churlish, there are some surgeons who feel that either is a justified approach. And, yet strong evidence for early overdelayed amputation suggest that making a good decision and acting on this early serves the patient best. Therefore, in a current reconstructive practice where there is both knowledge and experience of modern limb reconstruction and that of management of the amputee through modern prosthetics, the fundamental question here is surely “how best can I help this patient?”

When faced with a complex congenital limb deficiency or that after trauma or infection, the focus should be on the patient's quality of life as much as the quality of limb. The latter does not guarantee the former. In some, limb loss through surgery and substitution by a prosthetic is a real move to a better, albeit different, state of health, and it is this which should underpin modern discussions of amputation versus reconstruction. The process of reconstruction, especially if entailing multiple surgeries or, in the case of children with congenital limb deficiencies, multiple episodes of surgical treatments, may exact a cost that has yet to be quantified. A child's experience of childhood is irrevocably altered if all that remain as significant memories are the multiple hospitalizations and treatments encountered to reconstruct a limb. Is that state of health, at the end of all surgeries, better than that of the child who underwent an early amputation and prosthetic fitting and had experience of a childhood that allowed participation in peer-related activities on a more regular basis? Yes, these are two different states of health and I would argue that the better may be the one that provided more fulfilling experiences in childhood.

There is also the factor of complexity in limb reconstruction. While some conditions render themselves to predictable outcomes after reconstruction, others (usually severe longitudinal deficiencies) involve multiple operations of a complexity that should ideally be carried out by a small number of experts internationally. A worse outcome is almost guaranteed if these very complex procedures are attempted by those either insufficiently trained or practiced in these operations. Taking this into account and when the evidence of multiples studies confirm the parity of outcomes from amputation or limb reconstruction, surgeons can offer this option when complex reconstruction is not in their portfolio. Alternatively if the patient, after counseling, insists on limb preservation, then a referral to such a center with this ability would be advised.

Different cultures differ in their acceptance to an amputation but, as each society expands their knowledge through the Internet and with exposure to countless inspiring examples of amputees excelling (e.g., the Paralympics, the Invictus games), there will come a time – if not already here – when being an amputee carries no social stigma. What then becomes important is that it is not the surgeon's own acceptability or rejection of amputation as a procedure that influences the patient.

Limb amputation is a 21st-century option for reconstruction. It allows the surgeon to, for the suitable cases, take the patient to a better state of health. With the myriad of factors that can influence the decision between amputation and limb reconstruction – patient related, surgical team related, and cultural and economic – the choice must lie with individual circumstances.